What is the treatment for pulsatile tinnitus?

Treatment for Pulsatile Tinnitus

Treatment of pulsatile tinnitus is directed at the underlying vascular or structural cause identified on imaging, not at the symptom itself, because over 70% of cases have an identifiable and often treatable etiology. 1

Mandatory Diagnostic Workup Before Treatment

Pulsatile tinnitus requires urgent imaging evaluation to identify life-threatening causes such as dural arteriovenous fistula (which can cause catastrophic hemorrhage) or arterial dissection (which can cause stroke). 1, 2

First-Line Imaging Selection

• Order CT angiography (CTA) of head and neck with contrast when suspecting dural arteriovenous fistulas, arterial dissection, atherosclerotic carotid disease, sigmoid sinus abnormalities, or arteriovenous malformations. 1, 3

• Order high-resolution CT temporal bone (non-contrast) when suspecting paragangliomas, glomus tumors, jugular bulb abnormalities, superior semicircular canal dehiscence, or aberrant vascular anatomy. 1, 3

• If initial CT/CTA is negative but clinical suspicion remains high, proceed to MRI with contrast and MR angiography to evaluate for cerebellopontine angle lesions or subtle vascular malformations. 1, 4

• Digital subtraction angiography should be reserved for cases with objective pulsatile tinnitus, inconclusive noninvasive imaging, or definitive characterization of suspected dural AVF. 1, 4

Cause-Specific Treatment Algorithms

Vascular Causes (Most Common)

Atherosclerotic carotid artery disease (17.5% of cases):

• Medical management with antiplatelet therapy and statin therapy for atherosclerotic disease. 1
• Carotid endarterectomy or stenting for hemodynamically significant stenosis. 1

Arterial dissection (life-threatening):

• Anticoagulation or antiplatelet therapy as primary treatment. 3, 5
• Urgent intervention required to prevent stroke. 1

Dural arteriovenous fistulas (8% of cases, life-threatening):

• Endovascular embolization is the primary treatment modality. 1, 6
• Surgical disconnection if endovascular approach fails. 1
• Untreated cases can lead to hemorrhagic or ischemic stroke. 1

Arteriovenous malformations:

• Endovascular embolization, surgical resection, or stereotactic radiosurgery depending on size, location, and angioarchitecture. 1
• Treatment is essential given 2-3% annual hemorrhage risk with 10-30% mortality from first hemorrhage. 1

Venous Causes (Second Most Common Category)

Idiopathic intracranial hypertension with sigmoid sinus stenosis (second most common cause overall):

• Weight loss for overweight patients (particularly young women with headaches). 1
• Acetazolamide or topiramate for medical management. 1
• Venous sinus stenting is an emerging endovascular therapy showing high efficacy for PT resolution. 4, 6
• Optic nerve sheath fenestration or ventriculoperitoneal shunt if vision threatened. 1

Sigmoid sinus diverticulum or dehiscence:

• Surgical repair or endovascular embolization for severe cases. 3, 5
• Observation for mild cases without significant symptoms. 1

Jugular bulb abnormalities (high-riding jugular bulb or dehiscence):

• Surgical intervention for symptomatic cases causing significant disability. 3, 5
• Conservative management for asymptomatic or mildly symptomatic cases. 1

Tumor Causes (16% of Cases)

Paragangliomas (glomus tympanicum/jugulare):

• Surgical resection for small tumors. 1
• Radiation therapy (stereotactic radiosurgery) for larger tumors or poor surgical candidates. 1
• Observation with serial imaging for elderly patients or small asymptomatic tumors. 1

Adenomatous middle ear tumors:

• Surgical excision is the primary treatment. 1

Structural/Bony Causes

Superior semicircular canal dehiscence:

• Surgical repair (middle fossa or transmastoid approach) if symptoms are debilitating. 1, 3
• Conservative management with avoidance of triggers for mild cases. 1

Critical Clinical Pitfalls to Avoid

• Never dismiss pulsatile tinnitus as benign without imaging, as identifiable causes exist in >70% of cases and some are life-threatening. 1, 2

• Do not miss dural AVF, which requires high index of suspicion and appropriate vascular imaging, as it can present with isolated pulsatile tinnitus before catastrophic hemorrhage. 1

• Perform adequate otoscopic examination to avoid delayed diagnosis of vascular retrotympanic masses (paragangliomas) that are visible on examination. 1, 3

• Do not overlook intracranial hypertension in young, overweight women with headaches and pulsatile tinnitus, as untreated cases can lead to permanent vision loss. 1

• Avoid routine use of antidepressants, anticonvulsants, or anxiolytics for treating pulsatile tinnitus without addressing the underlying vascular or structural cause. 3, 5

• Do not recommend dietary supplements (Ginkgo biloba, melatonin, zinc) as primary treatment for pulsatile tinnitus. 3, 5

When No Cause is Identified

If comprehensive imaging (CT/CTA and MRI/MRA) is negative and no treatable cause is found (occurs in <30% of cases), symptomatic management includes:

• Cognitive Behavioral Therapy (CBT) for improving quality of life and coping mechanisms. 5
• Sound therapy or hearing aids if associated hearing loss is present. 5
• Reassurance that life-threatening causes have been excluded. 1